by Steven M. Crimando, BCETS, CHS-V, Behavioral Science Applications October 2017

Transcription

1 by Steven M. Crimando, BCETS, CHS-V, Behavioral Science Applications October 2017

2 When You Hear Hoofbeats In the late 1940 s, Dr. Theodore Woodward, a professor at the University of Maryland School of Medicine famously told interns, When you hear hoofbeats, think horses, not zebras. i The message to his students was simply, when assessing a situation, consider the more likely or common causes before exotic explanations. While horses are common, at least in Maryland, zebras are not. As applied to the risk of violence in hospital, healthcare and human service settings, most violence involves unarmed patient-to-staff assaults. Regarding gun violence, what is more common than active shooter situations, are shooting incidents. Active shooter events are the rarest, but most devastating form of violence in hospitals. But in the moment a shot is fired, it is not important to understand the shooter s motives or which category of violence the attack falls into; everyone must understand how to respond in the interest of survival. As such it is important to be prepared for both the hoofbeats of horses (i.e. shooting incidents ), as well as zebras (i.e. active shooter situations ), but to have an accurate understanding of the realities of hospital shootings. Recent incidents at hospitals in Indiana, New York, New Hampshire and Florida are powerful reminders of the special challenges associated with violence prevention and active shooter preparedness in hospital and healthcare settings. Any shooting incident in a hospital or healthcare setting is a nightmare scenario. Active shooter situations in hospitals are different from those in other environments in several critical ways that should inform plans, procedures and exercises. The large number of patients, visitors and medical staff on hand in hospitals means that a shooting incident may produce multiple casualties. But in efforts to prevent, respond to, and recover from hospital shootings, it is important to understand the distinction between an active shooter situation and a shooting incident.

3 The U.S. Department of Homeland Security defines an active shooter as, an individual actively engaged in killing or attempting to kill people in a confined and populated area. ii (DHS, 2013) In active shooter situations in non-hospital settings, the events are typically planned long in advance of the attack, and are instances of predatory or cold-blooded killing. In these situations target selection is usually random and the shooter usually has no prior relationship with the victims, but rather has selected the venue because it represents a target rich environment that will allow him (96% male) to kill as many people as possible before he is stopped. iii The motives for such shootings are multiple and complex. Many shots are fired; the attacker may be armed with multiple weapons, and possibly explosives, and in some instances has been equipped in tactical gear. Hospital shooting incidents tend to be acts of targeted violence and do not typically involve random victim selection. In hospitals, the shooter (91% male) more likely has specific targets in mind. Such instances usually arise from smoldering hostility and are instances of affective or hot blooded killing. Many involved former staff or patients who have been off the hospital s radar for some time. The most common scenarios in hospitals stem from a real or perceived grievance with current or former caregivers or coworkers whom the perpetrator believes have wronged him or his loved ones in some way. Some are instances of domestic violence that follow an employee from home to work; others are mercy killings of a terminally ill loved one, often ending as a murder/suicide. Motives for Hospital Shooting Incidents: Grudge/Revenge (27%) Suicide (21%) Ending life of ill relative (14%) Escape attempt by prisoner (11%) Societal violence (9%) Mentally unstable patient (4%) Many shooting incidents are spontaneous and emotionally driven. For example, in 23% of shootings within the Emergency Department, the weapon was a security officer's gun taken by the perpetrator when the opportunity presented itself. In hospital shooting incidents, fewer rounds are fired, fewer weapons are involved, and the most common victim is the perpetrator (45%). iv True active shooter situations evolve quickly and about 70% of the cases end within 5 minutes. v The shooter, applying the principles of surprise, speed and violence of action, seeks to create the highest casualty count possible before the police arrive. When the shooter transitions from being the hunter to hunted, he loses his tactical advantage, and

4 the incident ends one way or another quickly thereafter. Understandably, much attention has been given to those five minutes of terror in the response gap; that time between when the first shot is fired and when the first police arrive. This is a time when the action of victims, witnesses and bystanders can be the difference between life and death, so plans, training and exercises often focus exclusively on this narrow section of the overall event timeline. Sadly, we have learned from experience the psychological, social and economic damage done by a shooting can continue to impact individuals, families, organizations and communities for decades after the incident. Much less attention has been given to understanding and proactively planning to manage the postincident consequences of an active shooter attack or shooting incident in the hospital or healthcare setting. By understanding the critical challenges and action steps associated with the post-shooting environment leaders and decision-makers can better map out the road to recovery. As with other critical incidents it is helpful to apply a phase-specific approach to identify the mile markers along that road to ensure a timely and effective response to the complex post-shooting environment. Planning Along the Event Timeline As the first law enforcement personnel respond to 911 calls and reports of shots fired, they will quickly take command and control of the tactical aspects the situation. It will be necessary to proactively establish liaison between the organization s leadership team, the Hospital Incident Command Systems (HICS) and the law enforcement command structure (Incident Command System). There will be information and support needed from the organization to aid the police response. Floor plans and access to CCTV feeds or files can greatly help tactical leaders gain a better understanding of the operating environment, improve officer safety, and hasten the process of finding and stopping a shooter. At the onset, there will necessarily be a high level of collaboration and

5 coordination, but law enforcement officials are unlikely to give much direction about how the organization should address the pressing post-shooting challenges beyond the immediate response phase. Immediate Post-Shooting Phase The immediate post-shooting phase includes the first minutes to hours of the crisis. Life safety and survival remain the top priorities even though the shooter has been stopped. Within the scope of this paper, we will not address the issues of triage and emergency casualty care, and all that those activities involve. We will rather make the assumptions that medical personnel within the affected facility have planned and exercised casualty care and the response phase of an internal mass casualty scenario. In the immediate post-shooting, as the smoke begins to clear, there are a number of foreseeable challenges that can be addressed through pre-planning. These include: Assembly and Accountability of Evacuees In the initial attack many people, including employees, visitors, vendors and anyone who may have been onsite at the time of the incident, may have self-evacuated or followed evacuation instructions given by the organization or responding police to evacuate. Individuals in this group should be directed to predetermined assembly or muster points. Such assembly points should not be in adjacent parking areas since it is possible the attacker(s) may have also left improvised explosive devices (IEDs) in vehicles or in other nearby positions for a secondary attack on incoming responders. Upon arrival at an assembly point, evacuees should check in to begin an accountability process. It will be important for the organization s leaders to quickly establish the whereabouts of their personnel. Any employees who were out of the facility or at other locations at the time of the shooting should be notified there is an emergency onsite and not to return. Employees arriving at assembly points should also be asked and/or quickly

6 looked over to make sure they have not been hurt. Endorphins, often associated with the runner s high sensation, are powerful neuro-hormones that activate the body's opiate receptors, causing an analgesic effect. This means an injured person may not necessarily realize they have been hurt. There are examples of this effect even with gunshot wounds. Non-evacuating employees must also be accounted for. There are likely to be employees and others still inside a facility in the immediate wake of an attack. It will be important to know who they are, where they are, and if there are any immediate medical needs. Law enforcement officers employ a slow and meticulous clearing process to search the facility after an attack. They are always cautious that there may be other suspects and/or that the attacker(s) have carried other hazardous devices or substances into the environment. Employees who may have taken refuge in offices, closets or conference rooms should remain in place until informed by the responding officers that it is safe to move. It will be important therefore, for the organization s leaders to establish some channel of communications with those barricaded employees since they are unlikely to know the status of the event while in hiding. Informing the law enforcement command team of the whereabouts and status of those hunkered down can help them prioritize the discovery and release of those employees, and/or speed medical support to them if someone has been injured. Attend to basic needs, such as water and warmth or cooling, basic emotional support in the form of Psychological First Aid, and connection to loved ones as early as possible. Many individuals may also be witnesses, and as such, law enforcement officials may wish to interview and take statements from them before they leave. Coordinate the release of these employees with the law enforcement Incident Command structure. Evacuating employees gathered in assembly points should also be instructed to redirect any media questions to the Public Information Officer within the command system and not to speak to the media themselves. Family Reunification The greatest source of anxiety in a crisis is separation from loved ones and the paucity of information about their status. The organization s plans should envision the need for a Family Reunification Center (FRC) since loved ones of those in the targeted facility are likely to begin arriving quickly after learning about an attack. FRCs are non-medical legal operations, and are not coordinated by the local jurisdiction coroner/or medical examiner. The role of the FRC is to provide family members of victims or potential victims with information about status of the situation and of their loved ones. Planners should

7 consider indoor venues or at least the ability to relocate to an indoor setting in inclement weather. Current models of Family Reunification Centers now assume the possibility of up to 8-10 friends and family members converging on the reunification point given how quickly and widely information travels through new media channels and social media platforms. It will be important to control incoming traffic from family members attempting to reach the workplace and located loves ones. Having pre-printed signage (banners, placards, etc.) identifying the various functional areas (e.g., First Responder Staging, Media, Family Reunification, etc.) can help speed initiating and operating the reunification center and leaders should anticipate operating such a center for at least 24-hours post shooting. It will be important to identify the anticipated needs in such an environment, train and prepare some employees to provide leadership and support in those places, and/or develop relationships with community partners and other providers of post-disaster support services to ensure successful operations of such a complex and dynamic environment. EMS, emotional and spiritual support must be made available for overwhelmed family members. Depending on the duration of family support operations it is helpful to bring Employee Assistance Providers and more formal sources of mental health support, as well as clergy members into the mix as circumstances allow. The initial phase of a crisis is characterized by information seeking. Communication with family members as they assemble and await news of their loved ones is essential. A representative of the organization, working in concert with the Incident Command System s designated Public Information Officer (PIO) must be ready with timely, accurate, and relevant information to help alleviate the stress and frustration associated with waiting, but can also help prevent the emotional escalation of the group as a whole. Periodic updates from credible spokespersons and representatives must be made, even if there is no significant new information available.

8 In selecting a location for the FRC it is important to try to strike a reasonable balance between being too close and too far from the affected facility. When families feel too far removed they will often leave the FRC, believing that more news or better information will be available closer to the impacted location. Of course, it is unlikely unauthorized persons will be able to get near a working crime scene, and are therefore likely to become even more frustrated, as well as potentially traumatized by the sights and sounds of the emergency response. The ideal location for the FRC should be in a place with low stimulation, reduced distractions and away from the media or a curious public. Depending on scope and magnitude of the incident, the FRC may stay operational for 24-hours or more before transitioning to a jurisdictional Family Assistance Center (FAC) in the days to follow. As such, basic creature comforts must be in place, and a schedule to rotate the FAC staff should be established to avoid physical and emotional burnout. Other considerations at the FAC include the availability of: Child care Language skills (including sign language interpreters) Psychological support providers with the ability to assist persons of all ages and cultures Chaplains/Clergy Persons skilled in death notification and grief support In some states it is also likely that therapy dogs may also have a role in the FAC operation. For example, Connecticut lawmakers impressed with the effectiveness of therapy dogs in calming and comforting Newtown students and staff after the Sandy Hook Elementary School shooting passed legislation mandating the rapid response of specially trained volunteer Critical Incident Response Canine Teams to violent and traumatic events. vi It is important to remember for individuals and families gathered at a FAC, the hours and days ahead may be long and painful. Having a variety of different emotional support resources in place will be important and necessary. Media Management Leaders should anticipate local, national and possibly international media to descend on the location. Crisis communications is generally concerned with crafting the right message for various stakeholder groups in the wake of critical incident, while media management is focused on the logistics and interface with representatives of media

9 outlets. Both functions are important since any shooting incident is likely to draw a significant and immediate media response. While the Public Information Officer within the law enforcement command staff will be coordinating the interface with the media in terms of press conferences and the general release of information, it will still be critical for communications professionals within the affected organization to be working in concert with the PIO to coordinate both the message and logistics. The media often prefer to position camera teams near the family reunification site or in a place near evacuating employees to capture dramatic footage, but by negotiating with the PIO, the organization may be better able to protect the dignity and privacy of employees by limiting movement of reporters during and immediately following an incident. Coordinate with the Incident Command Staff to limit helicopter news crew access to air space immediately above the workplace can also be helpful. The organization s communications team must be thoughtful as to the backdrop for news cameras when selecting a Media Staging Area. Media often seek backdrops of the organization s facilities or distressed individuals and families if not redirected. As a general rule, the media should also be kept separate from families and staff while the emergency is ongoing and in the immediate post-crisis phase. Coordination with local law enforcement agencies may also be necessary for families who may experience intrusive media attention at their homes. In the immediate phase, messaging from the organization must clearly communicate care, concern, and compassion for the victims of the attack and those family members affected. Later messages can transition to themes of restoring normal operations as soon as possible and assuring employees the organization is a safe place for them to continue to work. By working closely with the PIO the organization s communicators will have a better sense of timing and when to begin to shift the tone and content of messages. It is critical for every leader to remember a shooting incident is a crime, that there will be and investigation, and likely litigation, potentially both civil and criminal. Legal counsel should be included in communications decisions as soon as reasonably possible.

10 Because information will need to be shared so quickly with concerned individuals and groups, those in the organization tasked with communications should consider the development of templates for different crisis events prior to actual events. Lessons learned by way of the many mass shooting incidents that have occurred have helped identify key messaging points, including: Empathy and concern for the victims of the attack Concern for affected family and friends Praise for dedicated and heroic responders and caregivers Information about the resumption/restoration or continuity of healthcare services Reassurance for staff and community members that the hospital is a safe and secure place to work and receive care Updated information about the status of the event IT and Communication Disruption IT and telecommunication disruption is a critical area of concern and represents an intersection with business continuity issues. There are several potential IT and telecommunications challenges: Key IT and/or telecom equipment may have been damaged or disabled in the attack. Access to data centers and server rooms, as well as other IT hubs may be limited or denied for hours or days. Local cell towers may be inundated with volume. It may be necessary to use automated information lines and the organization s website to provide updates, and to repurposing telephone call centers to help handle the flood of inquiries about the incident or the status of staff and patients. Crime Scene Management Since hospitals and healthcare facilities cannot be completely shut down easily, it becomes important to geographically contain the footprint of the crime scene. Hospital leadership must quickly establish communication with those elements of the law enforcement response involved in investigation and prosecution. It is most helpful if representatives of those programs can be involved in discussion pre-event, during planning and exercising, to help educate EMS and clinical staff members about the preservation of evidence while rendering care.

11 As early as possible investigators typically seek to photograph and/or videotape the crime scene to help ensure continuity in the location and relationship of various pieces of physical evidence, as well as the overall condition of the environment. Investigators also seek to interview those who were victims and witnesses of violence, as well as those with knowledge of the crime scene environment in its pre-attack condition. While it is important for healthcare staff to understand the needs of investigators, it is equally important that investigators understand the need to begin moving patients within the healthcare facility or to another healthcare facility to continue care. Law enforcement leaders to understand the complex issue for sustaining life during the response to a critical incident. Law enforcement responders and investigators may also require special instructions about operating in areas with specific risks, such as radiation or MRI suites with powerful magnets that can interact with their weapons and equipment. Early Recovery Phase The early phase includes the next hours to days along the incident timeline. While each active shooter situation or shooting incident is unique, there are commonalities in these situations that allow leaders and planners to foresee several likely concerns in the various phases. In the early phase, these include: Family Assistance Center (FAC) Operations Depending on the severity and scope of the attack, the law enforcement and emergency management officials from the local jurisdiction may determine a Family Assistance Center (FAC) is needed. The FAC is intended to be a one-stop service and support center for those affected by the violent incident. They are not typically managing by the hospital or healthcare organization, and are usually located in a place thought to be accessible to the public, but not necessarily on or near hospital grounds. The operation

12 tempo of the FAC also is different than the FRC. FRCs operations came seem like a sprint, whereas FAC activities may need to adjust the pace for a potential marathon. FACs can be operational for days and weeks post-incident, and in major attacks, much longer. Typical FAC functions include: Crime victim advocacy and support services Counseling and behavioral health services Collection of DNA samples for victim identification when necessary Ante mortem information collection Death notification, victims identification and temporary morgue operations FACs often are operated under the auspices of the medical examiner or coroner, but a strong support system is necessary. Credentialing and visitor management, donation management, child care, food service, and a wide range of logistical support is critical to the success of the FAC. Return of Personal Effects In the immediate phase, staff, ambulatory patients and visitors are likely to be running for their lives. As per their training in Active Shooter Response they may have left many important personal effects behind including car keys, purses or handbags, eyeglass, medications, laptops, phones and other devices, all of which can prove to be disruptive to daily life. Since the location will be designated a crime scene, investigators will need to examine everything left behind. They also will be hesitant to allow employees back into the facility to retrieve their belongings. It will be important to work with the Incident Command staff and investigators to determine the timing and method of returning personal belongings to staff members and others. It will be even more important to work out the return of personal

13 effects to those who may have been injured, or to the families to those who were killed. Law enforcement agencies, medical examiners/coroners, and crime victim assistance workers are familiar with this delicate task and can help an organization s leader facilitate this process. Supplemental Staff Support It is foreseeable that many staff members may be unable or unwilling to return to work in the days following a violent or traumatic event. Sadly, some may have been killed or seriously wounded; others may be too frightened, grief stricken or traumatized to quickly return. Some may take time off to attend funerals or memorials, thereby impacting staffing levels and shifts. Hospitals that may be part of larger healthcare systems may be able draw upon other hospitals and healthcare facilities within their organizations for staffing. Others may find it necessary to use medical staffing agencies to temporarily fill critical positions. This same mutual aid concept between partner or intra-organizational facilities also may be important in identifying alternate worksites for both clinical and non-clinical essential functions if the crime scene footprint, or structural damage prevents a timely return to normal operations. These arrangements may require written agreements prior to an incident, and be exercised to ensure they are feasible during crisis conditions. Behavioral Health Support Behavioral health support will be necessary for nearly all exposed or affected employees, and should be extended to their loved ones as well. Psychological First Aid (PFA) is the intervention of choice in the 0-48 hours of the traumatic incident. PFA is an every-person skill set, not reserved only for mental health workers. For a number of reasons, Employee Assistance providers may not be able to access the scene or initiate behavioral health support in the immediate aftermath of a violence event, therefore, it is helpful to have a cadre of potential Psychological First Aid responders on staff to provide peer support and rapid emotional aid for others who may have been the victims or witnesses to violence.

14 If the organization has a contracted Employee Assistance Program (EAP), that provider may have the capability to provide onsite support in the form of one-on-one and group sessions in the days that follow. The Incident Command staff from the emergency response agencies may also have information and connections to the local disaster mental health and crime victim assistance programs. If the organization has no formal relationship mental health service providers, the National Disaster Distress Helpline can be a viable resource. The helpline is operated by the federal Health and Human Services (HHS)-Substance Abuse Mental Health Services Administration (SAMHSA) on a tollfree, anonymous and confidential basis, 24/7/365. The number is , and for those who would prefer to communicate by text, the phrase TalkWithUs can be texted to There is also a TTY line at In addition to onsite behavioral health support for affected employees and their families, it will be important to remember that depending on the severity of the attack, there may be spontaneous vigils, funerals and memorial services at or near the affected facility in the early days after an attack, and it may be important to provide emotional support at those gatherings as well. Crime Victim Assistance While Crime Victim/Witness Advocates from county, state and federal agencies offer an array of important support services, a primary function is compensation to victims for their out-of-pocket losses associated with the crime. This compensation is broad and comprehensive, particularly in the area of long-term medical benefits, and can provide some financial relief to victims who often suffer long-term financial losses in addition to the physical and psychological harm caused by the crime itself. In many instances, crime victims support personnel can initiate services within the first several hours of an incident. Immediate financial support may be in the form of assistance with funeral expenses, or helping relatives from outside of the area quickly

15 travel to support their loved ones who may have been injured. Crime victims assistance may begin in the early phase, but may continue through the long process of recovery and aid in the many legal-justice challenges that victims can find overwhelming. Business Continuity There are a number of business continuity challenges specific to the early phase of shooting incidents and active shooter situations. These include: Loss of workplace: (part or all) due to damage, crime scene concerns and/or the psychological trauma of return to the scene of the crime Diminished workforce associated with deaths, injuries, acute grief, attendance to funerals Loss of technology due to ballistic damage, water and smoke, other forces Loss of critical supplies and equipment Disruption of supply chain, both up and downstream Depending on the scope of the crime scene and degree of damage to the facility, alternate worksites may be necessary to sustain or help quickly resume essential functions. Having a robust continuity plan in place prior to a violent event will help speed the recovery process. The hospital s business continuity professionals must play an active role in planning and exercising for a wide range of potential impacts, including blast damage from IEDs used in a violent attack. Disaster Restoration/Crime Scene Clean Up Once the physical location of the attack is no longer deemed a crime scene and control is handed back over to the hospital or healthcare organization, it will be important to have all damage and physical evidence of the attack repaired before bringing the workforce back into the environment. It is strongly recommended an

16 organization use a qualified and reputable disaster restoration or crime scene clean up service to handle such tasks and not allow the organization s own janitorial or custodial staff to do the cleanup and repair. In addition to the potential biohazards involved in the cleanup, it is potentially traumatizing to have employees who routinely have and will need to continue to clean and maintain the affected facilities exposed to the graphic or gruesome post-shooting environment. Spare employees that powerful experience and let others from outside the organization who are properly equipped and emotionally detached handle those tasks. Human Resource Concerns There are several likely human resource issues likely to emerge in the first days and spilling into the first weeks following a shooting incident. Some of the HR concerns naturally overlap with business continuity concerns, including: Reduction of workforce: Injured, killed, traumatized, grieving, and otherwise unable or unwilling to quickly return to work. Legal, moral and ethical challenges related to continuing payroll, extending sick leaves, and continuing medical benefits will surface soon after the attack. How will the organization handle absences due to emotional trauma? Will employees be asked to use up their sick time or vacation time if they require weeks or months before they are able to return to work? Will the organization hold their jobs? There will be a number of difficult questions for Human Resource leaders to tackle. These are just a few of what will likely be a long and complex list of HR issues. There are no easy answers to such questions. Each organization must struggle to find the right response based on their unique culture, vision and philosophies. Time Off for Responders and Crisis Team Members As the days become weeks, the operational tempo will shift and slow. Those involved with the organization s crisis management efforts will likely have been running a full speed, with little rest and high levels of stress for an extended time. It is wise to consider some down time and a period of decompression before returning to their normal duties. Operational stress control will be an important consideration, and those operating at high stress levels for days on end can begin to show signs of wear and tear, sometime affecting judgement and performance. Leaders must be realistic in what is expected of crisis team members.

17 Management of Political Response Mass violence is a social issue, as well as an organizational issue. Shooting incidents often become politicized. Mayors, Governors, at times even Vice Presidents and Presidents have visited the sites of mass shootings to make statements and support the victims and survivors of such events. VIP visits from politicians and celebrities can be highly disruptive. While some survivors may appreciate the show of support from a powerful leader or well-known personality, others find it disrespectful, even shameful, as attention may be turned away from the victims and survivor, and lights and cameras are directed at the special guest. Such VIP visits are a possibility and require active involvement by the organization s leaders in concert with civic leaders and emergency managers. VIP visits can be complicated and expensive, especially regarding increased security needs. Administrative Concerns While not within the scope of this paper, regulators and accrediting bodies have several levels of reporting and assessment of the incident that will require the attention of the organization s leadership. Note that when a facility has sustained damage as a result of violence, a post-incident accreditation survey may be required. Crisis Management, using both internal communications staff and perhaps external public relations consultants may also be necessary to formulate and execute a strategy to mitigate the impact on the organization s brand, reputation and market position. Executives will be drawn into many high-level strategic discussions, some requiring the involvement of the Board of Directors. Mid-Recovery Phase The weeks to months following an active shooter attack or shooting incident can be considered the mid-phase of recovery. The organization may have returned to normal business operations, but there will still be many vivid reminders of the incident. Some of the injured may still be hospitalized or in rehabilitation facilities. Others may not have returned to work due to the powerful emotional effects. There are other likely milestones in the recovery process that will represent challenges for individuals and for the organization.

18 Civil and/or Criminal Litigation A realistic assumption in any workplace shootings is that every bullet comes with a lawyer attached. If the shooter surrendered or survived the police response, criminal proceedings are likely to begin in the weeks to months after the attack. Media coverage of the trial or various processes leading up to a trial can be painful for victims and survivors, and trigger a host of different reactions that can be uncomfortable and disruptive at home and at work. Civil litigation in the form of negligence suits or wrongful death cases can be expensive and time consuming. They can also affect employee morale, recruitment and the organization s brand or reputation. It is also likely management and staff may be required to provide assistance in the investigation and prosecution of a violent crime. Staff members may be called as witnesses and participation in legal proceedings may bring back traumatic memories of the incident, requiring additional psychological support. Media coverage concerning related court cases can also stir up painful memories for many members of the staff and surrounding community. Ongoing Medical and Psychological Care It will be important to actively support and coordinate ongoing support for victims families, survivors and witnesses, including medical and psychological care. Some situations will evolve into worker s compensation or disability cases. HR and legal must be mindful of ADA issues related to employees with traumatic stress conditions and the impact on job performance, attendance and other issues.

19 After Action Reports Done too quickly following a violent event, the fog of war can cloud memory, judgement and decision-making, while waiting too long can result in important lessons fading from memory. The weeks or early months after an active shooter incident are a reasonable time frame to gather a working group to create an After Action Report (AAR) to capture important lessons learned and develop a corrective plan to make any needed changes to the organization s violence prevention/active shooter response plans. This is an important and sometimes painful process, since it means revisiting the details of the incident and critiquing the response in a constructive manner. It is equally important that any findings or recommendations be acted on quickly since failure to do so can create additional legal risk. It will be necessary to articulate and assign responsibility for completing any corrective or improvement tasks to specific people, with deadlines for completion, and a feedback mechanism to verify those tasks have been completed. Any changes made to the emergency response plans that flow from the corrective process should be tested to assure they are effective and understood by all concerned parties. Anniversary Planning The one-year anniversary of a violent attack can be an important milestone in individual and organizational recovery, but it can also be complicated and emotional. As such, it cannot be ignored, and any plans to commemorate the anniversary or to handle it in a deliberate low-key manner must begin early on. Anniversary events or memorials should be done with the staff and community, not to them. A violent attack represents a loss of control and feelings of extreme powerlessness and vulnerability. Any activities to commemorate the incident should involve a high-level of staff and community involvement and empowerment.

20 The anniversary represents an opportunity to take stock of the accomplishments of both individuals and the organization; reassess the needs of the organization; enhance and strengthen connections with stakeholders and continue creating partnerships that promote resilience and create a legacy. Forming a committee or working group in the months before the actual anniversary will give the group enough time to gather feedback and support for their plans. Depending on the magnitude and the effects of the shooting on the surrounding community, it may be important for the planning team to communicate and coordinate with civic leaders and others who may be planning anniversary events separate from the healthcare organization. In some instances coordination with state and federal partners will also be necessary and may require sufficient lead time. There are also myriad logistical concerns associated with anniversaries and memorials, including site security, vehicular and pedestrian traffic flow, media coverage, and psychological support for both organizers and participants. Long-Term Recovery Phase Long-term recovery is typically considered the one-year anniversary and beyond. As mentioned in the opening paragraphs of this paper, the physical and emotional impact of an active shooter situation or shooting incident can linger for decades, and sometimes an individual s entire lifetime. It is important for leaders and decision-makers to understand the long-term effects of violent and traumatic events. For example, the prevalence of post-shooting diagnoses (predominantly PTSD) in studies ranges from 10% to 36% vii as compared with about 11%-15% of the affected population developing such diagnoses after natural disasters. viii Compared with other types of critical incidents, mass shootings represent the greatest risk for acute traumatic stress disorder:

21 The rates of Acute Stress Disorder following traumatic incidents vary, with the highest rates associated with human-caused trauma: Typhoon 7% Industrial accident 6% Mass shooting 33% Violent assault 19% MVA 14% Assault, burn, industrial accident. 13% ix Lessons Learned Among the many types of crises that can affect a hospital or healthcare organization, gun violence in the form of shooting incidents and active shooter scenarios are some of the most disruptive and devastating. While the attack may be a surprise, the necessary action steps to effectively respond and recover from the incident are not. Proactive leadership is required to anticipate and address the post-incident consequences in a competent and compassionate manner. While it is of paramount importance to protect hospitals and healthcare organizations from a potential attack, and prepare staff to respond effectively to gun violence, it is also important to recognize it is not possible to prevent every incident. As such it is equally important organizations also develop processes for recovery and the resumption of operations. Recovery is an ongoing process that occurs in phases. Each organization and their staff will move through the phases of recovery in their own time and on their own terms. Crisis events are moments of truth; staff members, the community, key stakeholders and the media will remember how an organization handled the incident for a very long time. It is critically important to prepare for the entire life cycle of shooting attack, including anticipating and planning for the complex post-shooting challenges well before the first shot is fired.

22 About Everbridge Everbridge, Inc. (NASDAQ: EVBG) is a global software company that provides critical event management and enterprise safety applications that enable customers to automate and accelerate the process of keeping people safe and businesses running during critical events. During public safety threats such as active shooter situations, terrorist attacks or severe weather conditions, as well as critical business events such as IT outages or cyber incidents, over 3,000 global customers rely on the company s SaaSbased platform to quickly and reliably construct and deliver contextual notifications to millions of people at one time. The company s platform sent over 1.5 billion messages in 2016, and offers the ability to reach more than 200 countries and territories with secure delivery to over 100 different communication devices. The company s critical communications and enterprise safety applications, which include Mass Notification, Incident Management, IT Alerting, Safety Connection, Community Engagement, Secure Messaging and Internet of Things, are easy-to-use and deploy, secure, highly scalable and reliable. Everbridge serves 8 of the 10 largest U.S. cities, 8 of the 10 largest U.S.-based investment banks, all four of the largest global accounting firms, 24 of the 25 busiest North American airports and 6 of the 10 largest global automakers. Everbridge is based in Boston and Los Angeles with additional offices in San Francisco, Lansing, Beijing, London and Stockholm. Visit to learn more. References i Sotos, John G. (2006). Zebra Cards: An Aid to Obscure Diagnoses. Mt. Vernon, VA: Mt. Vernon Book Systems. ii U.S. Department of Homeland Security. (2013). Active Shooter: How to Respond. iii New York City Police Department. (2010 & 2012). Active Shooter: Recommendations and Analysis for Risk Mitigation. iv Kelen, G., Catlett, C., Kubit, J. and Hsieh, Y.H. (2012). Hospital-based shootings in the United States: 2000 to Ann Emerg Med. 60(6): e1. v Federal Bureau of Investigation. (2014). A study of active shooter incidents in the United States between 2000 and vi House Bill No. 6725, Public Act No AN ACT CONCERNING ANIMAL-ASSISTED THERAPY SERVICES. Passed June 6, vii Norris, F.H. (2007). Impact of mass shootings on survivors, families, and communities, PTSD Research Quarterly, Vol. 18, No. 3, 1-8. viii Norris, F.H. et al. (2002). 60,000 disaster victims speak: an empirical review of the empirical literature: Psychiatry, 65: ix Bryant, R.A. (2000). Acute stress disorder. PTSD Research Quarterly, 11(2), 1-7.

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